By Lee S. Shapiro, MD, FACP
Joints aren’t included in most lists of vital organs. But joint health is essential for an active life. Arthritis can erode the quality of life, even if it does not shorten it. Who among us doesn’t wish to retain the ability to walk, bend, reach, and grip? Who doesn’t wish to remain independent and free of pain? What is the image of youth but flexibility, agility, strength and speed?
Arthritis in some form will, at some time, affect more of us than any other health issue. For some, it may prove short term, localized, and a minor inconvenience; for others, it is life-altering and an unpleasant and intrusive part of everyday life. Unlike high cholesterol, hypertension, or elevated blood sugar, arthritis is hard to ignore. Arthritis is not one process but a name applied to all disorders involving joints. Tendonitis and bursitis, other common causes of pain, involve structures around joints, but are distinct from arthritis. Neurological disorders can cause pain and limit motion and strength but they involve muscles and nerves.
Arthritis can be a localized process resulting from prior injury or overuse of a specific joint. This is osteoarthritis, the most common form of arthritis, near universal in those who have lived a long and active life. Genetic predisposition to cartilage wear makes some much more susceptible than others to this process. No medicine can reverse existing wear and tear, though it may be possible to control pain and stiffness with exercise, physiotherapy, joint injection, and analgesics. Future treatments may render cartilage more resilient and less subject to damage. Joint replacement or joint resurfacing has brought quality of life back to many who developed advanced destructive changes.
Arthritis is not limited to late-life, but when it occurs in the young and middle-aged often there is an “inflammatory” cause. Rheumatoid arthritis is by far the most common of these ailments, but Lyme disease, psoriatic arthritis, ankylosing spondylitis, gout, and lupus are not rare. In these disorders, blood tests will most often reveal evidence of systemic inflammation. Onset can be sudden and involve multiple joints at once. Because these disorders are inflammatory, early intervention with appropriate therapy may result in resolution or near-resolution of symptoms. Accurate diagnosis essential
Accurate diagnosis is essential
Treatments for Lyme disease won’t help rheumatoid arthritis and treatment of rheumatoid arthritis won’t resolve gout. Review of past medical history and careful physical examination along with blood tests and imaging studies may all be needed to arrive at the correct answer. In some instances, particularly when gout is suspected, examination of joint fluid may be both the most rapid and accurate means of establishing a diagnosis. Imaging studies are often diagnostic in disease of long duration, but in early rheumatoid arthritis, x-ray studies may well be normal. It takes times for joint damage to develop.
We look for hints that help in diagnosis wherever we can find them. In psoriatic arthritis, which occurs in about 10% of individuals with psoriasis, the skin changes may be very subtle, even when the arthritis is severe. Small patches of psoriasis may be hidden beneath scalp hair. Nail changes may be masked by application of nail polish.
In the not so distant past, treatments of rheumatoid arthritis and psoriatic arthritis consisted of medications that did no more than diminish pain. In the past 20 years, a revolutionary change has occurred. We now have a growing number of “biologic” drugs, each of which targets a specific mediator of inflammation. We can realistically aim not just for pain relief, but for “remission,” turning off the inflammatory process and resolving all signs of joint inflammation.
No one medication works in everyone. There is still often a process of trial and error, but we hope soon to have the tools to enable us to more accurately predict which medication is the best option for any particular individual. These newer medications are powerful “immunosuppressive” drugs. Individuals taking them require close monitoring for the duration of therapy. Still difficult is deciding if and when a medication used successfully can be withdrawn. Long-term disease remissions may occur, but “relapse” sometimes happens when drugs are withdrawn. In this age of higher and higher co-pays, the incentive to stop therapy is often too powerful to resist. We need better markers so that we can more wisely advise our patients when it is safe or unsafe to alter an existing drug regimen. Some individuals may require lifelong therapy.
Inflammatory arthritis can certainly occur in the elderly, too. Pain and swelling of abrupt onset or sudden change in physical capacity should never be written off to the aging process. Feeling old overnight is never normal and almost always has a very treatable cause. Rheumatoid arthritis can develop at any age.
Our parents and grandparents, if they developed arthritis, were not as lucky as we are. We live in an era of revolutionary advances in both medical and surgical options for management of arthritis. While other medical advances may prolong your life, advances in arthritis treatment can improve your life.
Lee S. Shapiro, MD, FACP, FACR is a partner at The Center for Rheumatology, LLP locally and has authored numerous publications supporting his mission to educate on rheumatic diseases. Dr. Shapiro has an interest in the management of Scleroderma and is Director of the Steffens Scleroderma Center.